Home 
Contact 
Profile 
Videos 
Presentation at a training program for
family medicine resident s at the National Guard Madina 9-10 November 2014 by
Professor Omar Hasan Kasule Sr. MB ChB (MUK). M{H (Harvard), DrPH (Harvard)
Chairman of the Ethics Committee King Fahad Medical City.
WHAT
IS AN ETHICAL DILEMMA?
}
A problem with two or more competing solutions
}
No fixed or unanimous rules and regulations
}
Whatever solution is adopted has practical,
ethical, and legal implications
ASK
YOUR HEART?
}
Humans were created with the innate ability to
feel ‘right’ from ‘wrong’ – ask your heart first
}
In most cases the rational = the moral
}
In a few cases human rationality fails and a
higher moral guidance needs to be invoked
AUTHORITATIVE
SOURCES: At the National/International Levels
}
The Mufti of the Kingdom of Saudi Arabia
}
The Grand Ulama Authority
}
The Fiqh Academy of the Organization of the
Islamic Conference
}
The Fiqh Academy of the World Muslim League
AUTHORITATIVE
SOURCES: Local Level
}
Ethics Committee in the Hospital
}
Local Scholar
EXISTING
LAWS AND REGULATIONS
}
Code of Medical Ethics by the Saudi Council for
Health Specialties
}
Health Professions Practice Regulations by the
Saudi Council for Health Specialties
SOLUTION
USING THE 4 ETHICAL PRINCIPLES
}
Patient autonomy = patient decides
}
Beneficence = bring benefit
}
Nonmalefacence = cause no harm
}
Justice = treat all with equity
SOLUTIONS
USING MAQASID AL SHARI'AT
·
Protection of ddiin (morality)
·
Protection of life (life and health), hifdh al
nafs
·
Protection of progeny (family and procreation),
hifdh al nasl
·
Protection of the mind(psyche) hifdh al ‘aql
·
Protection of wealth(resources), hifdh al mal
SOLUTIONS
FROM PRINCIPLES OF THE LAW, qawaid al fiqh
·
THE PRINCIPLE OF INTENTION, qa’idat al qasd: we
consider the underlying intentions
·
THE PRINCIPLE OF CERTAINTY, qaidat al yaqeen:
evidence based decisions
·
THE PRINCIPLE OF INJURY, qaidat al dharar: cause
no harm; balance benefit vs injury
·
THE PRINCIPLE OF HARDSHIP, qaidat al mashaqqat:
exceptions in cases of necessity
·
THE PRINCIPLE OF CUSTOM or PRECEDENT, qaidat al
urf.: follow the procedures
SCENARIO
1:
·
An 80-year fully conscious and competent old man
with advanced incurable cancer needed palliative chemotherapy.
·
The family objected when the doctor wanted to
obtain informed consent from the patient because that would involve disclosing
the diagnosis which would make the patient very sad and depressed.
·
The family wanted to make the decision without
informing the patient.
·
What should the doctor do? Provide your moral
reasoning.
SCENARIO
2:
·
A 30-year old woman presented with classical
signs of acute appendicitis.
·
He consented to an operation to open the abdomen
and remove the inflamed appendix.
·
The surgeon found a previously undiagnosed
ovarian cyst and decided to remove it.
·
The removal was a simple and safe procedure that
would not increase the duration of the operation.
·
The head nurse refused because the patient had
not given consent.
·
What should the surgeon do? Provide your moral
reasoning.
SCENARIO
3:
·
A 90-year old in ICU with stage 4 widely
metastasized cancer and multi-organ failure was told by the doctors that there
was nothing they could do to reverse the course of the disease and that they
could only provide symptomatic treatment.
·
He asked to be discharged to die at home. His
children objected saying that he needed complex nursing that they could not
provide at home.
·
What should the healthcare workers do? Provide
your moral reasoning
SCENARIO
4:
·
The thoracic surgeon wanted to carry out a
de-bulking operation to decrease lung cancer mass to enable the patient breathe
easier and he told the patient of the high risk of death from hemorrhage.
·
The patient 85-year old patient was drowsy
because of medication and was suspected of suffering from dementia.
·
The doctor was not sure whether the patient was
capable of understanding the explanations given and making serious decisions
about the operation and he had no relatives nearby.
·
What should the doctor do? Provide your moral
reasoning.
SCENARIO
5:
·
A patient presented to the clinic with vague
complaints in the abdomen and worries about cancer.
·
Physical examination and investigations revealed
no pathology.
·
The doctor was angry with the patient for
wasting clinic time when he was in good health.
·
As the patient was leaving he told the doctor
that his uncle had died the week before of stomach cancer. The doctor did not
respond.
·
What should the doctor have done? Provide your
moral reasoning.
SCENARIO
6:
·
A young man sent for pre-employment examination
filled out a health questionnaire and mentioned no health problems at all.
·
Physical examination revealed a severely
dislocated shoulder and an unhealed acromial fracture.
·
When asked about them he admitted that they
caused him pain from time to time but that he was patient and did not care much
about them.
·
What should the examining doctor report? Provide
your moral reasoning.
SCENARIO
7:
·
An 80-year old diabetic man, whose son had died
last year from transfusion of mismatched blood, was admitted to the same
hospital for observation after falling at home.
·
He insisted that no procedure be done without
written approval by his physician son whom he wanted to sit by his bedside all
the time.
·
Nurses were inconvenienced by having to get
written permission for routine monitoring of vital signs and insulin
injections.
·
The nurses refused to comply to his wishes and
he refused to cooperate leading to a stand-off.
·
What should the doctor in charge do? Provide
your moral reasoning.
SCENARIO
8:
·
A young neurosurgeon planned to operate on a
patient with lumbar spinal injury that had a 5-10% chance of success.
·
He was perplexed about taking informed consent.
·
If he informed the patient that the operation
could go wrong and result in paraplegia with a 90% chance the patient would
refuse the operation.
·
If the operation was not carried out there was a
95% chance of further deterioration leading to paraplegia after a few months.
·
What should the neurosurgeon do? Provide your
moral reasoning.
SCENARIO
9:
·
A 30-year old patient of multiple sclerosis had
5 years while in good health designated her husband as the decision maker.
·
When she lost consciousness the doctors needed a
decision whether to put her on life support.
·
The husband who had by that remarried and lived
in a separate house decided against life support because it would prolong her
suffering.
·
Her father intervened and decided for life
support because that would be in her best interests.
·
What should the healthcare workers do? Provide
your moral reasoning.
SCENARIO
10:
·
A university professor with previous episodes of
transient stroke had written a directive and had it witnessed that if he lost
consciousness he would not like to be resuscitated.
·
Years later he was brought to the hospital
unconscious from head injuries sustained in a car accident.
·
The doctors reading his directive in his shirt
pocket decided not to resuscitate him but his wife insisted that he be
resuscitated.
·
What is the right course of action by the
doctors? Provide your moral reasoning.